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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
019200509
Report Date:
02/05/2021
Date Signed:
02/10/2021 08:50:44 AM
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
PACIFICA SENIOR LIVING UNION CITY
FACILITY NUMBER:
019200509
ADMINISTRATOR:
JOYCE LATIMER
FACILITY TYPE:
740
ADDRESS:
33883 ALVARADO NILES RD
TELEPHONE:
(510) 489-3800
CITY:
UNION CITY
STATE:
CA
ZIP CODE:
94587
CAPACITY:
110
CENSUS:
78
DATE:
02/05/2021
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
01:45 PM
MET WITH:
Joyce Latimer, Executive Director
TIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Luisa Fontanilla called facility to conduct case management in connection with an SOC 341 received by this agency. LPA spoke with Executive Director. LPA explained to Director purpose of the call.
LPA requested the following documents from the Director for Resident 1(R1):
1. Physician's Report
2. Needs and Services Plan
3. Incident Reports for the months of January and February 2021
A copy of this report was provided to Director via email.
SUPERVISOR'S NAME:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Luisa Fontanilla
TELEPHONE:
(510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE:
02/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/05/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
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